Surgery Only Slightly Better for Herniated Disc
Many patients with sciatic pain improve with other methods, studies find.
by Amanda Gardner
Tuesday, Nov. 21
(HealthDay News) -- Is surgery for sciatica resulting from herniated discs worth it?
The answer seems to be a cautious "yes," with experts noting that, for many patients, non-surgical methods may work just as well.
Two related studies, using different methodologies, found that back surgery did produce slightly better outcomes than non-surgical treatment. Both studies are published in the Nov. 22/29 issue of the Journal of the American Medical Association.
"The bottom line is that surgery works," said Dr. Todd Albert, co-author of one of the studies and vice chairman of the department of orthopedics and president of the Rothman Institute at Thomas Jefferson University in Philadelphia. "Non-operative treatment can work, and people can do well with it, but surgery worked better."
But surgery is definitely not for everyone, added another of the study's authors, Dr. Alan S. Hilibrand, associate professor of orthopaedic surgery at Jefferson Medical College.
"The person who comes in with leg pain from a herniated disc has a good chance of getting better with non-operative treatment and, unless they have certain unusual things going on, they should be treated non-operationally initially," he said. "If they're not getting better, they're likely to do well with surgery."
In fact, in general, the procedure should be reserved for herniated discs causing leg pain (sciatica), not for back pain caused by degenerated discs, Hilibrand explained.
Herniated discs occur when the nucleus of a spinal disc -- the cushioned part of the spine -- pushes into the spinal canal due to a tear or rupture. Many people recover from herniated disc on their own, but others require operations.
As the study points out, there are high variations in rates of this operation in the United States and, generally, lower rates internationally. That raises the question of whether and when it is appropriate to perform the procedure.
For the first study, close to 500 patients with herniated disc and sciatica were randomly assigned to undergo surgery or receive non-operative treatment, which included physical therapy and counseling.
Those undergoing surgery had slightly better outcomes in the areas of pain and physical function as well as severity of sciatica, satisfaction with symptoms and employment status.
One caveat: There was a high crossover, meaning many patients switched groups. This made direct comparisons more difficult, the authors said.
The companion article was an observational study which simply followed 743 patients with persistent sciatica who had chosen surgery or usual (non-surgical) care. All patients reported improvements over two years, although those who chose surgery experienced greater improvements.
How will the findings affect practice? Perhaps, not at all, experts said.
"I don't think it will necessarily change practice, but it will help surgeons to counsel patients," Albert said. "We could say to patients 'Look, we know you'll do great with surgery if you want to go forward, but if you're too scared, we might get you to do pretty well with other methods.' "
And it may help iron out the regional differences.
"There are a lot of people out there saying no one should have surgery, and they're probably not right about that," said Hilibrand, who is also director of medical education in the department of orthopaedic surgery at Thomas Jefferson University Hospital. "There are some saying you should have surgery right away, and that's probably not right, either. Hopefully, this will lead to more standardization of care."
Todd James Albert, M.D., vice chairman, department of orthopaedic surgery, Rothman Institute at Thomas Jefferson University and professor of orthopaedic surgery and neurosurgery, Jefferson Medical College, Thomas Jefferson University, Philadelphia; Alan S. Hilibrand, M.D., director, medical education, department of orthopaedic surgery, Rothman Institute at Thomas Jefferson University Hospital and associate professor of orthopaedic surgery, Jefferson Medical College, Thomas Jefferson University, Philadelphia; Nov. 22/29, 2006, Journal of the American Medical Association
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